Patient Registration & Privacy Form

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1Personal Information
2Medical Information
3Dental Information
4Privacy Agreement & Patient Consent

Personal Information:

Title

Name *

Surname *

DOB *

Address

Post code

Email *

Telephone Home

Mobile *

Postal Address (If different from above)

Emergency contact name, number and relationship

Medicare number & Ref

EXP

Name

Health insurance card number

reference no

EXP

How did you hear about Shine dental Group

Person responsible for payment: (if not you please fill section below)

Name

surname

DOB

Phone Home

Work

Mobile

Address

Post Code

Medical Information:

Physician's Name

Telephone

(women) Are you Pregnant?

Have you had any of the following?

Arthritis/Rheumatism Artificial Joints (knee, hip etc.) Asthma Blood pressure High or low Cancer, Tumour or other malignancy Chest pain Congenital Heart disease CJD: High / low Risk Heart alignment (heart attack, coronary artery disease, cardiac surgery) Heart Murmur Hepatitis or Liver disease HIV / AIDS Kidney Disease Osteoporosis or any other bone disorder Radiation or chemotherapy Diabetes Disability (physical or developmental) Emphysema or other lung disease Epilepsy Excessive bleeding or blood disorder Rheumatic fever Special Needs (Autism, Developmental Delay etc.) Stroke or other CVA Teberculosis

Have you had any previous illnesses? (if yes please state below)

Have you ever been advised to take antibiotics before dental treatment?

Do you have any allergies/allergic to any medication?

List medications you are currently taking:(also in particular medications for osteoporosis, blood thinners eg warfarin which can affect the dental treatment provided )

Have you ever had any compilations following dental treatment?

Dental Information:

Reason for today's visit?

Former Dentist:

Approximate date of last dental visit

Please tick if the following apply to you

Bad breath Broken fillings Blister on lips or mouth Burning sensation on tongue Chew on one side of mouth Cosmetic improvement/Makeover Dry Mouth Food collection between the teeth Clench or grind teeth Growths or sore spots in your mouth Gums swollen, tender or bleeding Jaw pain or tiredness Lip or Cheek biting Loose tooth Orthodontics (Braces) Sensitivity to pressure or irritants (cold, hots or sweets) Tooth replacement options (dentures, crowns, bridges, implants) Wisdom teeth problems Other

Privacy Agreement & Patient Consent

I understand the shine dental group and associated Medical & Dental clinics comply with the privacy act (1988) and as part of their privacy are committed to protecting the privacy of individuals and their personal information. by ticking and submitting below indicates that i have read the above and consent to Shine Dental Group collecting, using, storing and disposing of my personal information; the release of relevant personal information to other health professionals to allow quality dental care; inclusion in a recall register to be advices of the following up visits. I understand I may withdraw my consent for Shine Dental group to us and disclose my personal information (except when legal obligations must be met).

I have read and agree to the above *

Initials *

Your details are sent securely and only used by our clinic.

Monday	9:30 am–5 pm
Tuesday	Closed
Wednesday	9:30 am–5 pm
Thursday	Closed
Friday	9:30 am–5 pm
Saturday	Closed
Sunday	9:30 am–1 pm

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